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S4- los• sc r <br /> � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> /C'v • ( ENVIRONMENTAL HEALTH DIVISION <br /> U 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t <br /> (Complete in Triplicate) <br /> Application is hereby made to San`Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application Is made in coatpliancelvith San Joaquin County Ordinance No. 51+3 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address 18928 TRACY BLVD. City_TRACY ,. - Lot Size/Acreage <br /> M Owner's Name RON FAGUNDES1 Address 18928 TRACY BLVD. TRACY Phone 835-2421 <br /> Contractor AENNINfS.. BRnS__-„f1RTl I Address icense No.Z9f1R11 Phone . <br /> TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT LI DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK --1-00 't SEWER LINES 100 t DISPOSAL FLD. PROP. LINE �] <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom ff Manteca Dia. of Well Excavation Dia. of Well Casing u <br /> 1-X Domestic/Private )3(1 Gravel Pack� 00 Tracy Type of Casing._ P Specifications 1 6() q r h _ <br /> 1'} Public F1 Other ❑ Delta Depth of Grout Seal 100 , Ty a of Grout BENTONITE <br /> ! I Irrigation <br /> — Approx. pth I 1 Eastern Surface Seal Installed by <br /> HENNINGS BR�” DRILLING <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i IfJo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will'seive: !Residence Commercial— Other <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet,: Water,table depth * +. <br /> SEPTIC TANK. ❑ Typo/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to riearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS [ I Depth Size Number <br /> Cyt " <br /> SUMPS Lt Distance to nearest: Well Foundation Pro <br /> DISPOSAL PONDS 11party'line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must coal for all r uired inspections. complete drawinQ on reverse side. <br /> Signed <br /> Title: Data: MAY 17 , 1993 <br /> FOR DEPART EN USE ONLY <br /> Application Accepted by �--�5�� Area ,© <br /> _ k <br /> Ait <br /> r Grout inspection by Data Date Final Inspection by Date - 3 <br /> Additional Comments: <br /> Applicant - Retu n all copies to: San Joaquin County Public Health Services t <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> F @ <br /> I FO fAAMMOUNT DUE t, AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24{REV.tiMSl <br /> EH 14•25 'X9,�j <br /> MKK.!!J I CJ <br /> { <br />